Breaking the silence: a doctor's plea for clarity in end-of-life care

Six years ago, I met a man who was 93 years old. I sat down to listen to him, something we physicians don't do as often as we should in the long-term care setting.

"I want you to treat me like I'm 73," he said,

"What do you mean?" I asked.

"I don't want to be denied treatment just because I am 93 years old. I want you to give me the same treatment you would give a 73 year old."

In this country, we have banned assisted suicide, but this man knew that there were times people his age weren't treated for their diseases, and he wanted to be sure he was not one of them.

When it comes to being very old or being very sick, I have too often seen the do not resuscitate (DNR) order interpreted as an order not to treat a patient. The line between "do not treat" and assisted suicide is very thin.

It is frighteningly easy for a patient in the nursing home or a sick, elderly patient in the emergency room to lose his or her autonomy.

Years ago, I was working in a nursing home where an 84-year-old man had rectal bleeding. I sent him off to the next larger hospital so he could get a colonoscopy and a transfusion. I called the next morning to see how he was doing and when we might expect his return. I was told because he was so old, he "didn't want treatment," and they decided to let him die.

At another nursing home, an 86-year-old lady had a kidney infection because she had a kidney stone. I sent her to the next larger hospital to get her kidney stone addressed and her infection treated. The next day, when I called to see how she was doing, I was informed that they had decided not to treat her and to let her die because she was so old and so sick.

In a nearby town, an 87-year-old lady came in by ambulance. She was having an asthma attack. Her daughter came along with her. A friend of mine in the emergency room that day said she tried to send the 87-year-old patient off to the ICU for intubation.

The patient's daughter said, "No, you're not going to do that because she is a DNR, do not resuscitate." The patient was sedated and died early the next morning from respiratory failure.

At one of my nursing homes, I had a 95-year-old twin man with urosepsis who was talking incoherently. The other twin had no infection and was completely coherent. The family of the confused 95-year-old decided that he did not have a good quality of life and that he should be allowed to die from his urosepsis.

In another hospital, a 95-year-old male came in with urosepsis. He had three daughters. We had a long discussion about whether I should vigorously treat their father.

They asked, "Dr. Lindemann, can you return our dad to the state he was in before he got sick?

"Yes, I think I can."

They said, "Go ahead and treat him then."

I treated the man with urosepsis, and the next morning he had been restored to the condition he had been in before he was sick. Everyone was happy. Five years later, I saw him in my waiting room when he was 100 years old. He happened to be sitting next to a friend of his who was also 100 years old. Only in North Dakota can two 100-year-olds walk into your clinic and carry on a conversation.

People in North Dakota live a long time, possibly because many are farmers who often work in the fields until they are 80. In any case, I have seen far too many elderly patients become entrapped in the lack of a distinction between do not treat and DNR.

Alan Lindemann is an obstetrics-gynecology physician.